Question

Mrs. Evans has just become eligible for Medicare. However, she also has a supplemental policy through Anthem and would like to better understand who pays what. Since she has an appointment next week for her annual physical, she has called to get more information about this new insurance. Explain how Medicare and supplemental policies are billed. Which is primary? What if the primary does not pay the entire claim?

Answer 1

Generally, Medicare pays 80% of allowed expenses after the patients meets the annual deductible. To compensate for the remaining 20%, many patients enrolls in the supplemental policies. These supplemental plans may cover the annual Medicare deductible and 20% co - insurance left over by Medicare. The supplemental plans don't cover the expenses that Medicare does not approve, however. Some Medicare supplemental plans accepts claim directly from Medicare. This process is called as cross over claim submission. Patients having this plans must inform Medicare about the Medicare supplemental policies with all details, and the effective date. After this, Medicare starts processing the claim, sends the claim directly to the second payer and the provider is paid in a more timely manner. This is how Medicare and supplemental policies are billed.

Medicare is primary because it pays the first.

If the primary does not pay the entire claim, then the claim is sent to the secondary payer for consideration of the remaining balance for payment. Sometimes, it may also be further sent to tertiary or quaternary payers for the payment of remaining balance.